Indian Country Month in Virology teleECHO Clinic Sign-In

Thank you for attending today's Indian Country Month in Virology teleECHO session. The 1 hour long session includes an opportunity to engage in didactic sessions focused on up-to-date information on clinical care and emerging health topics focusing on viral infections.

Please complete the sign-in information below for today's clinic attendance.

Question Title

* 1. Please choose the date of the Virology ECHO Clinic you are attending:

Date of Clinic

Date

Question Title

* 2. Please Enter Your Contact Information. (If you would like a copy of the clinic's slides, please include a valid email address.)

First Name

Last Name

Tribe/Tribal Organization/Clinic Name (No acronyms, please.)

City/Town

US State/Territory

Canadian Province (If applicable)

Email Address

Question Title

* 3. What is your professional licensure?

DMD/DDS

Pharmacist

Behavioral Health

Other (please specify)

Question Title

* 4. Is your organization affiliated with an IHS (Indian Health Service), Tribal, or Urban (I/T/U) organization. Select one:

IHS

Tribal

Urban

Not applicable

Question Title

* 5. Please select which IHS Service Area your tribe/ tribal organization/ clinic is located in?

Alaska

Albuquerque

Bemidji

Billings

California

Great Plains

Nashville

Navajo

Oklahoma City

Phoenix

Portland

Tucson

Not applicable

Question Title

* 1. Please choose the date of the Virology ECHO Clinic you are attending:

Question Title

* 2. Please Enter Your Contact Information. (If you would like a copy of the clinic's slides, please include a valid email address.)

Question Title

* 3. What is your professional licensure?

Question Title

* 4. Is your organization affiliated with an IHS (Indian Health Service), Tribal, or Urban (I/T/U) organization. Select one:

Question Title

* 5. Please select which IHS Service Area your tribe/ tribal organization/ clinic is located in?

Question Title

* 6. What question(s) do you have relating to Virology? Our faculty will respond directly if an email is listed above.